5122-29-29 Assertive community treatment (ACT) service.

(A) Assertive community treatment (ACT) is a collaborative, multidisciplinary team approach that shall include, at a minimum, behavioral health counseling and therapy service, mental health assessment service, pharmacologic management service, community psychiatric supportive treatment (CPST) service, self-help/peer support service, mental health crisis response service, substance abuse services, and supported employment services.

ACT services are provided to an individual with a major functional impairment(s) and/or behavior which present a high risk to the individual due to severe and persistent mental illness and which necessitate high service intensity. ACT services are also provided to the individual's family and other support systems. A client receiving ACT services may also have coexisting substance abuse, mental retardation/developmental disabilities, and/or physical health diagnoses. The service is available twenty-four hours a day, seven days a week.

The purpose/intent of ACT team services is to provide the necessary services and supports which maximize recovery, and promote success in employment, housing, and the community.

(B) In addition to the definitions in rule 5122-24-01 of the Administrative Code, the following definitions apply to this rule:

(1) "Competitive employment" means activity conducted as part of a community job for which anyone can apply and for which the individual is paid at least minimum wage.

(2) "Crisis response" means the immediate access and availability of the ACT team, by phone and face-to-face, as clinically indicated, to the client or essential others, and which may include crisis stabilization, safety planning, and the alleviation of the presenting crisis.

(3) "Essential other" means an individual who has regular contact and emotional or functional significance to the person served including family, friends, guardians, landlords, neighbors, etc.

(4) "Peer specialist" means an employee who has experienced serious and persistent mental illness, and who provides direct services, including social and emotional support, coupled with instrumental support, to persons receiving mental health services. A peer specialist promotes recovery through training, role modeling and sharing experiences, and facilitates recovery by providing hope, encouragement, self-determination, validation, and connection to the community.

(5) "Supported employment" means a group of services which assists and supports a person choosing, obtaining, and maintaining competitive employment according to his/her preferences and without requiring prevocational activities.

(C) ACT certified agencies shall be certified to provide behavioral health counseling and therapy service, mental health assessment service, pharmacologic management service, and community psychiatric supportive treatment (CPST) service in accordance with Chapters 5122-24 to 5122-29 of the Administrative Code.

(D) Agencies shall develop clearly identified admission criteria which shall be reflective of the intensive nature of the service. Admission criteria shall include attention to:

(1) Diagnosis, including co-occurring disorders;

(2) Psychiatric service utilization history;

(3) Symptoms; and

(4) Functioning.

(E) The agency must demonstrate that each ACT team meets, at a minimum, the following staff requirements and qualifications:

(1) Designated team leader, who is qualified to supervise the service;

(2) Psychiatrist, including a minimum ratio of .40 full-time equivalent psychiatrist per one hundred clients receiving ACT services. Each ACT team shall have no more than three psychiatrists. The ACT team psychiatrist(s) may collaborate with a nurse practitioner(s) and/or clinical nurse specialist(s) to fulfill part of the psychiatrist(s)'s roles and responsibilities, provided that the nurse practitioner(s) and/or clinical nurse specialist(s) has a nursing specialty in mental health or psychiatric mental health;

(3) A substance abuse team member, including a minimum ratio of one full-time equivalent substance abuse team member per one hundred clients receiving ACT services:

(a) Prior to providing the service, each substance abuse team member receives an assessment of initial training needs based on the skills and competencies necessary to provide ACT service. A training and supervision plan shall be developed based on this assessment ensuring the substance abuse team member has or will obtain within six months the necessary skills and competencies, which may include:

(i) Engagement strategies;

(ii) Motivational strategies; and

(iii) Relapse prevention.

(b) An agency with more than one ACT team may be exempt from this requirement on one or more, but not all, of their ACT teams, providing all of the following conditions are met:

(i) The agency has at least one ACT team for dually-diagnosed individuals with alcohol and other drug service needs. This specialized team shall include a substance abuse team member; and

(ii) The agency's ACT service description, and ACT policies and procedures shall describe the client population needs served by each agency ACT team. In addition, the policies and procedures shall:

(a) Include the requirement that each client receiving ACT services and in need of alcohol and other drug services is served on an ACT team that includes a substance abuse team member; and

(b) Specify the procedures to ensure a client on a team without a substance abuse team member, but who is later assessed to be in need of substance abuse services, receives all ACT services from an ACT team with a substance abuse team member;

(c) All actions by the substance abuse team member and ACT team shall be in compliance with division (B) of section 3793.06 and section 4758.02 of the Ohio Revised Code.

(4) Registered nurse, including a minimum ratio of 1.0 full-time equivalent registered nurse per one hundred clients receiving ACT services. Each registered nurse shall have a specialty or documented competency in psychiatry;

(5) Vocational specialist, including a minimum ratio of 1.0 full time equivalent vocational specialist per one hundred clients receiving ACT services. Prior to providing the service, each vocational specialist receives an assessment of initial training needs based on the skills and competencies necessary to provide ACT service. A training and supervision plan shall be developed based on this assessment ensuring the vocational specialist has or will obtain within six months the necessary skills and competencies, which may include:

(a) Supported employment;

(b) Job placement;

(c) Individualized job development; and

(d) Benefits planning; and

(6) Prior to providing the service, each peer specialist receives an assessment of initial training needs based on the skills and competencies necessary to provide ACT service. A training and supervision plan shall be developed based on this assessment ensuring the peer specialist has or will obtain within six months the necessary skills and competencies, which may include:

(a) Recovery;

(b) Peer support;

(c) Consumer advocacy organizations; and

(d) Psychiatric advance directives:

(i) education and advocacy; and

(ii) information and referral.

(F) The agency must demonstrate that each ACT team member's roles and responsibilities include, at a minimum, the following:

(1) The team leader:

(a) Provides direct supervision of team members; and

(b) Provides direct services.

(2) The psychiatrist:

(a) Provides clinical leadership to the ACT team in assessment, treatment planning, general healthcare, medical and psychosocial approaches; and

(b) Collaborates with each nurse practitioner and/or clinical nurse specialist, when these staff are utilized to fulfill part of the requirement in paragraph (F)(2) of this rule, in assessment, treatment planning, general healthcare, medical and psychosocial approaches, and a review of each ACT client's progress and treatment.

(3) The psychiatrist, along with the nurse practitioner and clinical nurse specialist when these staff are utilized to fulfill part of the requirement in paragraph (F)(2) of this rule, provides consultation and training to other ACT team members regarding the client's medical psychiatric care, including pharmacologic management needs.

(4) The substance abuse team member:

(a) Provides training to other ACT team members on the signs, symptoms and early identification of alcohol and other drug use and abuse, and the disease of alcoholism and drug dependency;

(b) Assists in coordinating individual treatment planning including aftercare and recovery support services for each client actively involved in alcohol and other drug treatment;

(c) Assists each client receiving drug and alcohol treatment in becoming involved with self-help support groups;

(d) Assists each client receiving drug and alcohol treatment in developing and maintaining social support networks; and

(e) Ensures that each client referred by the ACT team for alcohol and other drug treatment is referred to an individual or program licensed or certified to provide alcohol and other drug treatment.

(5) The registered nurse:

(a) Conducts health assessments;

(b) Coordinates with other health providers; and

(c) Provides training to other ACT team members to help them monitor psychiatric symptoms and medication side effects.

(6) The vocational specialist:

(a) Provides training to other ACT team members to help them integrate interventions to support vocational goals;

(b) Liaisons with other providers of vocational rehabilitation services, if applicable;

(c) Provides or makes appropriate referral for benefits planning; and

(d) Provides a full range of supported employment services. Eligibility is based upon client choice, and efforts are made to engage the client in supported employment regardless of diagnosis, symptoms, work history, substance use, or treatment compliance. Supported employment activities must include:

(i) Interventions to achieve competitive employment. Volunteer jobs, sheltered employment, and enclaves shall not be suggested to a client as preparatory to employment, or as long-term vocational goals;

(ii) Interventions individualized to the client's job preferences, life-style, and mental health coping skills;

(iii) Commencing the employment search within four weeks after the client expresses a desire to work;

(iv) Time unlimited follow-along services. Contact with the client and employer, as appropriate, shall continue for the duration of the job; and

(v) Utilizing a job termination, if any, as a learning opportunity, and beginning a new employment search within four weeks.

(7) The peer specialist:

(a) Engages the client, and provides outreach and support; and

(b) Provides training and education to other ACT team members and clients on:

(i) Recovery;

(ii) Peer support;

(iii) Consumer advocacy organizations; and

(iv) Psychiatric advance directives:

(a) Education and advocacy; and

(b) Information and referral.

(G) The agency must demonstrate that each ACT team:

(1) Consists of a minimum of 4.0 full-time equivalent direct care staff members;

(2) Serves no more than one-hundred twenty clients; and

(3) Provides a minimum of a one-to-fifteen direct service staff-to-client ratio, excluding psychiatrists, and nurse practitioners and/or clinical nurse specialists when these staff are utilized to fulfill part of the requirement in paragraph (F)(2) of this rule.

(H) Each month the agency must demonstrate that ACT staff provide each client a minimum of the following service contacts for the ACT services specified in paragraph (C) of this rule:

(1) Three face-to-face service contacts. At least sixty-five percent of all face-to-face service contacts shall occur in the community; and

(2) Six total service contacts.

(3) Clinically appropriate reasons for the inability to implement any portion of this paragraph shall be documented in the ICR.

(I) The agency must demonstrate that the ACT team has a minimum of one contact per month with family/essential others, with the consent of and choice by the person served.

(J) The agency must demonstrate that each month sixty-five percent or more of the ACT team clients shall receive contact by more than one ACT team member.

(K) Each ACT team shall meet a minimum of four times each week to plan and review ACT client progress. Telephone conferences are acceptable. Each psychiatrist, as well as each nurse practitioner and clinical nurse specialist when these staff are utilized to fulfill part of the requirement in paragraph (F)(2) of this rule, shall attend a minimum of one team meeting each week. The team shall document attendance and participation at this meeting, as all on-duty ACT team staff are expected to attend.

(L) Each ACT team is responsible for crisis response twenty-four hours a day, seven days a week. Crisis response may be provided through written agreement with another agency, as long as at least one member of the ACT team is accessible to the provider agency, and is available to the client and/or essential other as needed. The agreement shall specify the responsibilities of the ACT team and the provider agency.

(M) The ACT team shall be involved in psychiatric hospital admissions and discharges.

(1) The team is involved in the decision for psychiatric inpatient admissions. The team shall document any instance in which they were unable to collaborate with psychiatric admitting staff.

(2) The team shall collaborate with the psychiatric inpatient treatment team for planning hospital discharges.

(N) For a minimum of ninety days, or until the client has stated his or her desire to discontinue ACT services, the ACT team shall attempt at least two face-to-face contacts per month for a client who has discontinued ACT services unexpectedly. Such attempts and client response, if any, shall be documented in the ICR.

(O) Assertive community treatment service shall be provided and supervised by staff who are qualified according to rule 5122-29-30 of the Administrative Code.

Effective: 03/22/2012
R.C. 119.032 review dates: 12/30/2011 and 03/22/2017
Promulgated Under: 119.03
Statutory Authority: 5119.61(A) , 5119.611(C)
Rule Amplifies: 5119.61(A) , 5119.611(C)
Prior Effective Dates: 7-1-2005, 1-9-2006, 8-23-2007, 12-13-2007, 7-1-2009